Suture anchor and method

ABSTRACT

Suture anchors and associated methods are disclosed having suture securing features able to lock suture ends extending from a body tissue, such as from a bone tunnel.

CROSS-REFERENCE TO RELATED APPLICATIONS

This application is a continuation-in-part of U.S. patent application Ser. No. 13/674,837, filed Nov. 12, 2012, which claims the benefit of U.S. Provisional Application No. 61/560,694, filed Nov. 16, 2011, and U.S. Provisional Application No. 61/597,138, filed Feb. 9, 2012, all of which are hereby incorporated by reference.

FIELD OF THE INVENTION

The invention relates to suture anchors and their method of use.

BACKGROUND

A variety of surgical procedures require the attachment of something relative to a surgical site. For example, in surgery relating to the skeletal system, it is often advantageous to attach soft tissue, suture, implants, and/or other items in or adjacent to a joint. For example, ligaments, tendons, fascia, other capsular material, and/or muscle may be attached to an adjacent bone to affect a repair of a joint. Such joints may include any joint in a patient's body such as the joints of the hands and feet, ankle, wrist, knee, elbow, hip, shoulder, and spine. For example, it is often advantageous to pass a suture through a portion of a bone to form a transosseous attachment to the bone.

SUMMARY

Aspects of the invention provide devices and methods to attach one or more sutures to a bone.

In one aspect of the invention, a method of repairing soft tissue includes forming a bone tunnel through a bone adjacent to the soft tissue to be repaired, the bone tunnel having at least first and second spaced apart openings at the surface of the bone; providing a suture and an anchor, a first portion of the suture being attached to the suture anchor and a second portion of the suture being free; placing the second portion of the suture through the bone tunnel and the soft tissue; placing the anchor into one of the bone tunnel openings; and connecting the second portion of the suture to the anchor.

In another aspect of the invention, a method of repairing soft tissue includes, after tensioning the suture, provisionally connecting a second portion of a suture to an anchor such that tension on the suture is maintained while the provisional connection is easily reversed, and evaluating a soft tissue repair.

In another aspect of the invention, a method of repairing soft tissue includes connecting a second portion of a suture to an anchor by advancing the insert into a longitudinal passage in the anchor.

In another aspect of the invention, a method of repairing soft tissue includes inserting a portion of a suture into an aperture in an insert and then advancing the insert into an anchor.

BRIEF DESCRIPTION OF THE DRAWINGS

Various examples of the present invention will be discussed with reference to the appended drawings. These drawings depict only illustrative examples of the invention and are not to be considered limiting of its scope.

FIG. 1 is a partial side sectional view of an illustrative implant and method according to the present invention;

FIGS. 2 and 3 are partial side sectional views of an illustrative implant and method according to the present invention;

FIGS. 4 and 5 are partial side sectional views of an illustrative implant and method according to the present invention;

FIG. 6 is a partial side sectional view of an illustrative implant and method according to the present invention;

FIG. 7 is a partial side sectional view of an illustrative implant and method according to the present invention;

FIG. 8 is a partial side sectional view of the implant of FIG. 7 in use in an alternative method;

FIG. 9 is a partial side sectional view of an illustrative implant and method according to the present invention;

FIG. 10 is a perspective view of an illustrative implant according to the present invention;

FIG. 11 is a perspective view of the implant of FIG. 10;

FIG. 12 is a side elevation view of the implant of FIG. 10;

FIGS. 13-15 are sectional views taken along line 13-13 of FIG. 12 showing an aspect of the operation of the implant of FIG. 10;

FIGS. 16-20 are partial side sectional views showing a method of using the implant of FIG. 10;

FIG. 21 is a partial side sectional view of the implant of FIG. 10 in use in an alternative method;

FIG. 22 is a top plan view of an illustrative implant according to the present invention;

FIGS. 23-26 are side sectional views taken along line 23-23 of FIG. 22 showing an aspect of the operation of the implant of FIG. 22;

FIGS. 27-30 are partial side sectional views of an illustrative method of using the implant of FIG. 22;

FIG. 31 is a top plan view of an illustrative implant according to the present invention;

FIGS. 32-33 are partial side sectional views of an illustrative method of using the implant of FIG. 31;

FIG. 34 is a side sectional view of an illustrative implant according to the present invention; and

FIG. 35-37 are partial side sectional views of an illustrative method of using the implant of FIG. 34.

DESCRIPTION OF THE ILLUSTRATIVE EXAMPLES

Minimally invasive surgery is surgery used to gain access to deeper parts of the human body through small incisions. Such surgery may range from mini-open surgery to arthroscopic surgery. Mini-open surgery is generally understood to mean surgery performed through small incision(s) under direct vision as opposed to arthroscopic (or endoscopic) surgery where surgery is performed through one or more stab incisions in which the arthroscope (or endoscope) is used for visualization. In arthroscopic surgeries, the size of the stab incisions generally range from 1 mm to 10 mm. The illustrative examples depict arthroscopic surgical techniques but it is to be understood that the techniques could be performed in any minimally invasive or open technique. The following illustrative examples depict implants and techniques to pass a suture through a portion of the head of the humeral bone at the shoulder of a human patient and fix the suture there to repair damaged soft tissue associated with the shoulder joint. Instruments and techniques according to the present invention may be used to anchor a suture to any bone, at surgical sites anywhere in a patient's body, and for any purpose. The terms “suture” and “suture strand” are used herein to mean any strand or flexible member, natural or synthetic, able to be passed through a bone tunnel and useful in a surgical procedure. The term “transverse” is used herein to mean to cross at an angle; i.e. not parallel. The term includes, but is not limited to right angles. The term “bight” is used herein to mean a bend or loop formed in the intermediate portion of a suture.

A human left shoulder joint is used to provide context for illustrative examples of a surgical technique. The subacromial space, between the humeral head and the undersurface of the acromion, is a potential space for surgical repair. This space is partially occupied by the subacromial bursa. Soft tissue layers overlie the shoulder joint. These layers define a soft tissue zone including the skin, subcutaneous tissue, muscles and bursal tissue. Instruments are inserted through the soft tissue zone via stab incisions and access canulae can be inserted through these stab incisions to facilitate the insertion and withdrawal of surgical instruments. The thickness of this soft tissue zone varies by patient and by location from a few millimeters to several centimeters.

Referring to FIG. 1 an osseous attachment device includes an implant 100 having an elongated shaft 102 extending from a proximal end 104 to a distal end 106 along an axis 108. The shaft 102 engages an elongated flexible strand to hold it relative to a bone. For example, FIG. 1 depicts a bone 120 and soft tissue 122 to be attached to the bone 120 adjacent a skeletal joint; e.g. a proximal humerus and a portion of a rotator cuff. An elongate flexible strand 124 such as a suture having first and second ends 126, 128 is passed through the soft tissue 122 and into the bone 120 at a desired attachment site. The implant 100 is inserted into the bone 120 to capture and retain the ends 126, 128 to hold the soft tissue 122 adjacent the bone 120.

For example, in a shoulder repair procedure, an elongate strand 124 in the form of at least one closed suture loop may be passed through the soft tissue 122 of the rotator cuff and the first end 126 of the loop placed in the bone 120 such as by placing it into a preformed tunnel or impacting it into the bone on a driver to simultaneously form a tunnel and insert the first end 126. In the illustrative embodiment of FIG. 1, the first end 126 is positioned in first tunnel 129. A hook 110 is formed adjacent the proximal end 104 of the implant 100 with a hook opening facing distally. The hook 110 is engaged with the second end 128 and inserted into the bone along a path intersecting the first end 126. The implant 100 and second end 128 may for example be impacted directly into the bone to simultaneously form a second tunnel 130 and insert the implant, or alternatively, they may be inserted into a preformed tunnel. In the illustrative embodiment of FIG. 1, one or more, optional barbs 112 project from the shaft 102 outwardly and distally. When the implant 100 intersects the first end 126, one or more of the barbs 112 engage the first end 126 such that when insertion of the implant 100 is complete, the implant 100 engages and secures both ends of the elongate strand 124 to retain the elongate strand in the bone 120 and secure the soft tissue 122 with the first end being secured distally and the second end being secured proximally. Alternatively, the barbs 112 may be omitted and the shaft 102 alone pass through the suture loop to constrain it within the bone. With the use of a preformed loop, the soft tissue attachment is accomplished without the need for the user to tie any knots.

Referring to FIGS. 2 and 3, an osseous attachment device includes a locking implant 200 and an elongated member 220. In the illustrative embodiment of FIGS. 2 and 3, the implant 200 is in the form of an interference screw. The implant 200 includes an elongated tapered body 202 extending from a wider, proximal end 204 to a narrower, distal end 206 along an axis 208. A spiral thread 210 is formed on the exterior of the body 202 and the body includes an axial through passage 212. In the illustrative embodiment of FIG. 2, the separate elongated member 220 is in the form of a suture carrier that includes an elongated shaft 222 extending from a proximal end 224 to a distal end 226. The distal end 226 may be tapered or otherwise sharpened to ease insertion into bone. A transverse opening 230 is formed through the shaft near the distal end 226. An optional groove or reduced diameter region may be provided proximal of the opening 230 to ease in cutting or breaking the elongated member 220 to a desired length. The passage 212 of the implant and shaft 222 of the elongated member are sized for axial translating engagement. The elongated member 220 is used to capture the ends of an elongated flexible strand and the implant 200 is used to lock the elongated flexible strand to hold the elongated flexible strand adjacent to a bone.

For example, in a shoulder repair procedure, an elongate strand 240 in the form of at least one suture defining a first end 242 in the form of a loop, or bight, and having second ends 244, may be passed through the soft tissue 246 of the rotator cuff. The first end 242 is inserted into the bone 248 such as by placing it into a preformed tunnel 243 or impacting the elongate strand 240 into the bone on a driver to simultaneously form a first tunnel and insert the first end 242. The second ends 244 are passed through the transverse opening 230 of the elongated member 220 and the elongated member 220 and second ends 244 are inserted into the bone along a path that intersects the first end 242. The elongated member 220 and second ends 244 may for example be impacted directly into the bone to simultaneously form a second tunnel and insert elongated member 220 and second ends 244, or alternatively, they may be inserted into a preformed second tunnel 245. When the elongated member 220 intersects the first end 242, the distal end 226 of the elongated member 220 captures the first end 242 distally and prevents it from being withdrawn upwardly through the bone such that the first end 242 is retained distally in the bone. The second ends 244 may then be pulled to feed slack through the transverse opening 230 and tension the elongated strand 240 and approximate the soft tissue to the bone. The locking implant 200 is then engaged with the proximal end of the elongated member 220 and advanced into the bone 248. The locking implant 200 presses the elongated strand 240 against the bone in an interference engagement to lock the second ends 244 in the second tunnel 245. The locking implant also prevents the elongated member 220 from exiting the second tunnel 245 thus the locking implant locks both ends of the elongated strand 240 relative to the bone 248 and secures the soft tissue 246. The soft tissue attachment is accomplished without the need for the user to tie any knots.

Referring to FIGS. 4 and 5, an osseous attachment device includes a locking implant 300 and a suture carrier 320 similar to that of FIGS. 2 and 3. In the illustrative embodiment of FIGS. 4 and 5, the implant 300 is in the form of an interference screw having a cylindrical body 302 extending from a proximal end 304 to a distal end 306 along an axis 308. A spiral thread 310 is formed on the exterior of the body 302. In the illustrative embodiment of FIGS. 4 and 5, the separate suture carrier 320 is in the form of a ring having an aperture 322. The suture carrier 320 is used to capture the ends of an elongated flexible strand and the locking implant 300 is used to lock the elongated flexible strand to hold the elongated flexible strand adjacent to a bone. While a suture carrier has been shown in the form of a ring it may have other forms such as a sphere, rod, or other suitable shape that can receive a suture in sliding relationship.

For example, in a shoulder repair procedure, as shown in FIGS. 4 and 5, an elongate strand 340 in the form of at least one suture defining a first end 342 in the form of a loop, or bight, and having second ends 344, may be passed through the soft tissue 346 of the rotator cuff. The first end 342 is inserted into the bone 348 such as by placing it into a preformed first tunnel 343 or impacting the elongate strand 340 into the bone on a driver to simultaneously form a tunnel and insert the first end 342. The second ends 344 are passed through the aperture 322 of the suture carrier 320 and the suture carrier 320 and second ends 344 are inserted into the bone along a path that intersects the first end 342. The suture carrier 320 and second ends 344 are passed through the loop of the first end 342. Applying tension to the elongated strand 340 causes the loop of the first end 342 to close around the second ends 344 and trap the suture carrier 320 in the bone such that the ends 342, 344 are retained in the bone. Further pulling on the second end 344 causes slack to feed through the suture carrier and tension the strand 340 to approximate the soft tissue to the bone. The locking implant 300 is then advanced into the bone 348. The locking implant 300 presses the elongated strand 340 against the bone in an interference engagement to lock the elongated strand 340 relative to the bone 348 and secure the soft tissue 346. The soft tissue attachment is accomplished without the need for the user to tie any knots.

Referring to FIG. 6, an osseous attachment device includes an implant 400. In the illustrative embodiment of FIG. 6, the implant 400 is in the form of an interference screw. The implant 400 includes an elongated body 402 extending from a proximal end 404 to a distal end 406 along an axis 408. A spiral thread 410 is formed on the exterior of the body 402. A head 412 is formed near the proximal end 404 and defines a distally facing shoulder 414 at the junction of the head 412 and body 402. The implant 400 is used to capture both ends of an elongated flexible strand 420 and hold the elongated flexible strand 420 adjacent to a bone.

For example, in a shoulder repair procedure, as shown in FIG. 6, an elongated strand 420 in the form of at least one suture having first ends 422 and a second end 424 defining a loop, may be passed through the soft tissue 426 of the rotator cuff. The first end 422 is inserted through the bone 428. The second end 424 is engaged with the distal end 406 of the implant 400. The first end 422 may be tensioned to remove slack and press the soft tissue against the bone. The distal end 406 of the implant 400 may be braced against the bone or engaged with the bone tunnel to facilitate tensioning the strand 420. The implant 400 is then driven into the bone to lock the ends 422, 424 relative to the bone. The second end 424 is trapped beneath the head 412 adjacent the shoulder 414 of the implant 400 and the first end is trapped between the thread 410 and bone 428.

Referring to FIGS. 7 and 8, an osseous attachment device includes an implant 500. The implant includes an elongated body 502 extending from a proximal end 504 to a distal end 506 along an axis 508. An axial bore 510 extends into the body 502 proximally to distally. A transverse body aperture 512 extends through the body and intersects the axial bore 510. A head 514 is formed near the proximal end 504 and defines a distally facing shoulder 516 at the junction of the head 514 and body 502. The head 514 is interrupted by opposed grooves aligned with the aperture 512. Opposed flat surfaces 518 on the exterior of the body are aligned with the grooves and the aperture 512 and the grooves and flat surfaces 518 provide clearance to allow a suture to slide between the body 502 and a bone tunnel wall. The exterior of the body further includes annular projections 520 on opposite sides of the body 502 between the flat surfaces 518. The annular projections engage a bone tunnel wall to retain the implant 500 in the bone tunnel. The axial bore 510 is threaded proximally and receives a piston-like plunger 522 in axial threaded engagement such that the plunger is responsive to rotation to move between a first position in which the plunger 522 distal end is substantially not overlapping the transverse body aperture 512 and a second position in which the plunger 522 overlaps at least a portion of the transverse body aperture 512.

The implant 500 is used to capture both ends of a strand and hold the strand adjacent to a bone. For example, in a shoulder repair procedure, as shown in FIG. 7, an elongated strand 550 in the form of at least one suture having a first end 552 and a second end 554 defining a loop, may be passed through the soft tissue 556 of the rotator cuff. The first end 552 is inserted through the bone 558. The second end 554 is looped around the body 502 such as by inserting the implant 500 through the loop of the second end 554 until the loop comes to rest against the shoulder 516. The first end 552 is passed through the aperture 512. The first end is then passed along the flat surface 518 and through the groove in the head. The implant 500 is inserted into the bone until the shoulder 516 abuts the bone 558. The first end 552 of the strand 550 is tensioned to remove slack and press the soft tissue against the bone. The plunger 522 is advanced toward the transverse aperture 512 until the distal end of the plunger 522 traps the second end 554 of the strand in the axial bore 510 such that the first end 552 is fixed distally in the aperture 512 and the second end 554 is trapped proximally under the shoulder 516.

FIG. 8 illustrates an alternative method of using the implant 500. In the illustrative method of FIG. 8, both ends 552, 554 of the suture are passed through the transverse aperture 512 of the implant 500 and along the flat surface 518 and through the groove in the head. The implant 500 is inserted into the bone until the shoulder 516 abuts the bone 558. The ends 552, 554 of the strand 550 are tensioned to remove slack and press the soft tissue against the bone. The plunger 522 is advanced toward the transverse aperture 512 until the distal end of the plunger 522 traps the ends 552, 554 of the strand distally in the aperture 512 intersecting the axial bore.

Referring to FIG. 9, an osseous attachment device includes an implant 600 similar to that of FIGS. 7 and 8 except that the implant 600 of FIG. 9 includes a transverse aperture 602 through the implant body 604 and a transverse aperture 606 through the plunger 608 and the plunger 608 is advanced by pressing it into the body 604 rather than by threading. In this example, the first end 610 of the suture strand is passed through the body aperture 602 and the second end 612 is passed through the plunger aperture 606. When the plunger 608 is advanced in the body 604, the distal end of the plunger traps the first end 610 in the body aperture 602 and the plunger aperture 606 and head 614 trap the second end 612. The relationship between the plunger length and positions of the apertures 602, 606 may be adjusted to provide for simultaneous locking of the suture ends, distal locking of the first suture end 610 before proximal locking of the second suture end 612, or proximal locking of the second suture end 612 before distal locking of the first suture end 610.

Referring to FIGS. 10-15, an osseous attachment device includes an elongate implant body 700 and a plunger or piston 750 receivable in the body 700. The implant body extends from a proximal end 702 to a distal end 704 along an axis 706. An axial passage 708 extends into the body proximally to distally along the axis 706. First and second transverse apertures 710, 712, forming a distal aperture pair, extend through the body 700 distally and intersect the axial passage 708. The apertures 710, 712 are offset toward opposite sides of the axis 706 and the second aperture 712 is offset proximally from the first aperture 710. Third and fourth transverse apertures 714, 716, forming a proximal aperture pair, extend through the body 700 proximally and intersect the axial passage 708. The apertures 714, 716 are offset toward opposite sides of the axis 706 and the fourth aperture 716 is offset distally from the third aperture 714. The body 700 has radially extending ridges 718 that taper distally to aid in retaining the body in a tunnel. Opposed flats 720, 722 extend along opposite sides of the body 700 adjacent the apertures 710, 712, 714, 716 to provide clearance for suture ends extending alongside the body 700. A head 724 formed near the proximal end extends radially outwardly beyond the body diameter and includes radially extending ridges 726. Opposed flats 728, 730 extend along opposite sides of the head 724 in circumferential alignment with the body flats 720, 722 and apertures 710, 712, 714, 716 but spaced radially outwardly from the axis 706 farther than the flats 720 and 722. Alignment slots 732, 734 are formed on the distal end of the head to provide a rotational alignment keyway for a driver (not shown). The distal end 704 of the body tapers distally to ease insertion into a tunnel.

The plunger 750 includes an elongated body 752 extending from a proximal end 754 to a distal end 756 along an axis 758. The distal end of the plunger tapers distally to ease insertion into the body 700 and separate suture strands as will be more fully described below. The plunger 750 has faceted sides 705 defining elongated vertices, or ridges 707, at the intersection of adjacent facets. The plunger 750 is receivable in the passage 708 in axial translating relationship.

One or more suture strands may be passed through the apertures 710, 712, 714, 716 and locked with the plunger 750. The plunger can lock any number of suture strands passing through any number of the apertures. Referring to FIG. 13, a suture strand 760, 762 has been passed through each of apertures 710 and 712. The plunger 750 has been advanced distally into the passage 708 until the distal end 756 of the plunger 750 is just short of touching the suture strands 760, 762. As can be seen in FIG. 13, since the apertures 710, 712 are offset outwardly from the axis 706, the tapered distal end 756 of the plunger, which is coaxial with axis 706, is directed between the strands 760, 762.

Referring to FIG. 14, the plunger has been advanced further distally and the distal end 756 has moved between the strands 760, 762 and begun pressing them outwardly toward the side wall of passage 708.

Referring to FIG. 15, the plunger 750 has been advanced fully into the passage 708 and tightly compresses the strands 760, 762 between the plunger sides and passage 708 such that the suture strands are locked firmly relative to the body 700. The plunger 750 presses the strands sideways into the sidewall of passage 708 and the suture strands are highly compressed by the ridges 707. Since the ridges 707 are able to slide smoothly over the sutures while compressing them, the advancing plunger 750 locks the suture strands without dragging the sutures axially along the passage 708 and therefore the suture strands are locked with little or no change in the suture tension.

FIGS. 16-19 depict an illustrative example of a method of using the implant of FIGS. 10-15 in a surgical procedure to secure a portion of a rotator cuff to a proximal humerus using knotless transosseous suture fixation.

Referring to FIG. 16, first and second intersecting bone tunnels 770, 772 have been formed in the head of a humeral bone 774 of a shoulder joint. Suture strands 776 have been passed through the bone tunnels with first ends 780 exiting superiorly from the first bone tunnel and passing through a portion of the rotator cuff 778 and second ends 782 exiting laterally from the second bone tunnel 772. The first ends 780 have been passed through the proximal apertures 714, 716 of the implant body 700 and the second ends 782 have been passed through the distal apertures 710, 712. The second bone tunnel 772 is sized to be a press fit with the ridges 718 of the body 700.

Referring to FIG. 17, the body 700 has been inserted into the second bone tunnel 772 up to the base of the head 724. In this position, the suture ends 780, 782 may be pulled to remove slack from the suture strands 776 and the strands will slide easily through the bone tunnels and implant body 700.

Referring to FIG. 18, the body 700 has been further inserted into the second bone tunnel 772 so that the head is flush with the bone and the head compresses the suture strands between the head and bone. Since the head 724 extends radially outwardly farther than the body 700, driving the head into the bone will compress the suture strands as shown in a provisionally locked state. In this state, the sutures will not slip easily but a user can supply sufficient force to the ends 780, 782 to overcome the frictional provisional lock and perform a final tensioning of the suture strands 776. The plunger 750 is shown aligned with the passage 708 ready to be inserted after final tensioning of the suture strands 776 is completed.

Referring to FIG. 19, the plunger 750 has been inserted partway into the passage 708 so that the suture ends 780 passing through the proximal aperture pair are locked but the suture ends 782 passing through the distal aperture pair can still be tensioned if desired. In this way the plunger 750 provides a sequential locking action relative to the proximal and distal apertures.

Referring to FIG. 20, the plunger 750 has been fully seated locking all of the suture strands and the loose suture ends have been cut off flush with the bone.

FIG. 21 illustrates an alternative method of using the implant 700 in which separate suture strands are passed through separate portions of a soft tissue and the loose ends of each strand are secured using the distal and proximal pairs of apertures respectively. A first suture strand 800 is attached to the rotator cuff 778 such as by way of a mattress stitch or other suitable stitch. The ends 802 of the first suture strand 800 have been passed through the distal apertures 710, 712 of the implant body 700. A second suture strand 804 is attached to the rotator cuff 778 such as by way of a mattress stitch or other suitable stitch. The ends 806 of the second suture strand 804 have been passed through the proximal apertures 714, 716 of the implant body 700. The implant body 700 is inserted into the bone tunnel 772 and the sutures tensioned and secured as describe in the previous illustrative example.

FIGS. 22-37 depict osseous attachment devices in which one or more sutures are preattached to the device. One advantage of this arrangement is a reduction of the number of suture ends that must be managed by a surgeon.

Referring to FIGS. 22-26, an osseous attachment device, or bone anchor 900, includes an elongate implant body 902 and an insert 950 in the form of a plunger or piston receivable in the body 902. The implant body 902 extends from a proximal end 903 to a distal end 904 along an axis 906. An axial passage 907 has a proximal portion 908 extending into the body 902 proximally to distally along the axis 906 and a distal portion 910 extending into the body 902 distally to proximally along the axis 906. A transverse aperture 912, extends through the body near the distal end 904 and intersects the axial passage 907. The distal end 904 of the body tapers distally to ease insertion into a tunnel.

The insert 950 includes an elongated body 952 extending from a proximal end 954 to a distal end 956 along axis 906. The distal end 956 of the insert tapers distally to ease insertion into the body 902. The body 952 of the insert includes an axial through bore 958 extending between the proximal and distal ends. The body 952 further includes a transverse aperture 959. The insert 950 is receivable in the proximal portion 908 of the passage 907 in axial translating relationship.

One or more suture strands 960 are attached to the distal end 904. In the illustrative example of FIGS. 22-26, a pair of suture strands are attached by passing a first portion 962, in this case a first end of each suture, through the axial passage 907, and knotting it distal to the distal end so that the first portion 962 is attached to the anchor body and cannot pull through the axial passage 907. In the illustrative example of FIGS. 22-26, the insert 950 is preassembled to the body 902 by partially inserting it into the proximal portion 908 of the axial passage 907 in a first, open position as shown in FIGS. 22 and 23. A second portion 964 of the suture strands 960 is passed through the body and axial bore 958 of the insert 950. The suture is provided in a stowed position as shown in FIGS. 22 and 23 with the suture extending along the axis 906.

In use, the second portion 964 of the suture can be retrieved from the anchor 900 by pulling the suture through the body aperture 912 as shown in FIG. 24. The second portion 964 may then be engaged with tissue or other material to be anchored to the bone and the second portion 964 passed through the insert aperture 959 as shown in FIG. 24. The insert 950 may be advanced to a second, provisionally locked position as shown in FIG. 25. In this position the insert presses the suture against the end of the anchor body 902 and prevents the suture from slipping while a user evaluates the soft tissue repair. If adjustments are needed, the insert 950 may be retracted to allow the suture to be adjusted. Once all adjustments are made, the insert 950, is advanced further to a third, fully locked position as shown in FIG. 26 in which the suture is tightly compressed between the wall of the proximal portion 908 of the passage and the insert body 950.

Various alterations may be made to the illustrative example of FIGS. 22-26. For example, the suture may be a single strand, multiple strands, and/or one or more continuous loops of suture. The insert 950 may optionally be supplied separate from the anchor body 902 and the suture passed through the insert aperture 959 while the insert 950 is disengaged from the anchor body 902. Likewise, the suture may be attached to the anchor body 902 by any suitable means including knotting, molding the anchor body 902 onto the suture, crimping, and or adhering the anchor body 902 to the suture.

FIGS. 27-30 depict an illustrative example of a method of using the implant of FIGS. 22-26 in a surgical procedure to secure a portion of a rotator cuff to a proximal humerus using knotless transosseous suture fixation.

Referring to FIG. 27, a bone tunnel 970 has been formed in the head of a humeral bone 972 of a shoulder joint such that the bone tunnel has at least first and second spaced apart openings 974, 976 at the surface of the bone. The bone tunnel may be formed straight through the bone, along a curved path, by intersecting tunnels (as shown), of in other suitable configurations so that the tunnel is transosseous and provides at least first and second openings. In FIG. 27, a medial tunnel 978 has been formed below a portion of a rotator cuff 980 and a lateral tunnel 982 has been formed horizontally in the proximal humerus 972. The medial and lateral tunnels intersect to form a continuous tunnel through the bone. A guide 984 has been positioned in alignment with the lateral tunnel 982.

Referring to FIG. 28, the anchor 900 has been advanced through the guide 984 and into the lateral tunnel 982 with the suture in the stowed position of FIGS. 22 and 23. The anchor aperture 912 is positioned in alignment with the medial tunnel 978. An instrument 986 having a hook 988 at one end is advanced through the medial tunnel 978 until it engages the suture within the anchor body 902. In the illustrative embodiment, a flexible instrument 986 capable of passing through a portion of the guide 984 is depicted. Any number of graspers, hooks, loops and/or other suitable suture retrieving instruments could be used to engage the suture.

Referring to FIG. 29, the second portion 964 of the suture has been retrieved through the medial bone tunnel and engaged with the rotator cuff 980 by passing the second portion 964 up through the rotator cuff 980 over the lateral margin of the rotator cuff and through the insert aperture 959. The suture may be provisionally locked as shown in FIG. 25 and the rotator cuff repair evaluated.

Referring to FIG. 30, once the sutures are positioned as desired, the insert 950 is advanced into the fully locked position to connect the second portion 964 of the suture to the anchor 900 and excess suture 990 may be trimmed.

Referring to FIG. 31, an osseous attachment device, or bone anchor 1000, similar to that of FIGS. 22-26, includes an elongate implant body 1002 and an insert 1050 in the form of a plunger or piston receivable in the body 1002. The implant body 1002 extends from a proximal end 1003 to a distal end 1004 along an axis 1006. An axial passage 1007 is formed into the proximal end to receive the insert 1050 in axial sliding relationship. The distal end 1004 of the body tapers distally to ease insertion into a tunnel.

The insert 1050 includes an elongated body 1052 extending from a proximal end 1054 to a distal end 1056 along axis 1006. The distal end 1056 of the insert tapers distally to ease insertion into the body 1002. The insert body 1052 includes a transverse aperture 1059.

One or more suture loops or strands 1060 are attached to the distal end 1004 of the anchor body 1002. For example, a first portion 1062 of the suture may be knotted, molded to the anchor body, crimped, adhered, or otherwise attached to the distal end. In the illustrative example of FIG. 31, a single suture strand is shown threaded through an opening 1064 in the distal end and knotted to retain it in the distal end 1004. A second portion of the suture 1060 extends distally away from the distal end of the anchor body 1002 to a second, free end 1066.

In use, the second portion of suture 1060 is engaged with tissue or other material to be anchored to the bone and passed through the aperture 1059 in the insert; e.g. by passing free end 1066 through the aperture 1059. The insert 1050 is inserted into the anchor body 1002 and advanced to a provisional locked position in which the insert 1050 presses the suture 1060 against the end of the anchor body 1002 and prevents the suture from slipping while a user evaluates the soft tissue repair. If adjustments are needed, the insert 1050 may be retracted to allow the suture to be adjusted. Once all adjustments are made, the insert 1050, is advanced to a fully locked position. The insert 1050 may be provided separate from the anchor body 1002 as shown in FIG. 31 or it may be preassembled similar to the illustrative example of FIGS. 22-26. Likewise, the insert 1050 may be positioned in multiple positions relative to the anchor body 1002 as described with respect to FIGS. 22-26, including a first, initial engaged position, a second, provisional locked position, and a third, final locked position.

FIGS. 32 and 33 depict an illustrative example of a method of using he implant of FIG. 31 in a surgical procedure to secure a portion of a rotator cuff to a proximal humerus using knotless transosseous suture fixation similar to that of FIGS. 27-30. In FIG. 32, the second portion of the suture 1060 has been passed through the bone tunnel 1070, through the rotator cuff 1080, and through the aperture 1059 of the insert 1050. In FIG. 33, the anchor body 1002 has been inserted into a lateral opening of the bone tunnel 1070. This insertion may be aided by pulling on the suture 1060 to guide and pull the anchor body 1002 into the bone tunnel 1070. For example, simultaneous pushing on the proximal end 1003 of the anchor body 1002 and pulling on the suture 1060 may be used to seat the anchor body 1002. Next, the insert 1050 is advanced to provisionally lock the suture and, once any desired adjustments are made, further advanced to the fully locked position of FIG. 33.

Referring to FIG. 34, an osseous attachment device, or bone anchor 1100, similar to that of FIG. 31, includes an elongate implant body 1102 and an insert 1150 in the form of a plunger or piston receivable in the body 1102. The implant body 1102 extends from a proximal end 1103 to a distal end 1104 along an axis 1106. An axial passage 1107 is formed into the proximal end to receive the insert 1150 in axial sliding relationship. A transverse aperture 1112, extends through the body near the distal end 904 and intersect the axial passage 1107. The distal end 1104 of the body tapers distally to ease insertion into a tunnel.

The insert 1150 includes an elongated body 1152 extending from a proximal end 1154 to a distal end 1156 along axis 1106. The distal end 1156 of the insert tapers distally to ease insertion into the body 1102.

One or more suture loops or strands 1160 are attached to the proximal end 1103 of the anchor body 1102. For example, a first portion of the suture 1162 may be knotted, molded to the anchor body, crimped, adhered, or otherwise attached to the distal end. In the illustrative example of FIG. 31, a single suture strand is molded to the proximal end 1103. A second portion of the suture 1160 extends proximally away from the proximal end of the anchor body 1102 to a second, free end 1166.

In use, the second portion of suture 1160 is engaged with tissue or other material to be anchored to the bone and passed through the aperture 1112 in the anchor body 1102; e.g. by passing free end 1166 through the aperture 1112. The insert 1150 is inserted into the anchor body 1102 and advanced to a provisional locked position in which the insert 1150 presses the suture 1160 against the edge of the aperture 1112 and prevents the suture from slipping while a user evaluates the soft tissue repair. If adjustments are needed, the insert 1150 may be retracted to allow the suture to be adjusted. Once all adjustments are made, the insert 1150, is advanced to a fully locked position. The insert 1150 may be provided separate from the anchor body 1102 or it may be preassembled as shown. Likewise, the insert 1150 may be positioned in multiple positions relative to the anchor body 1102 as described with respect to FIGS. 22-26, including a first, initial engaged position, a second, provisional locked position, and a third, final locked position.

FIGS. 35-37 depict an illustrative example of a method of using he implant of FIG. 34 in a surgical procedure to secure a portion of a rotator cuff to a proximal humerus using knotless transosseous suture fixation similar to that of FIGS. 27-30. In FIG. 35, the second portion of the suture 1160 has been passed through the rotator cuff 1180, through the bone tunnel 1170, and through the aperture 1112 of the anchor body 1102. In FIG. 36, the anchor body 1102 has been inserted into a lateral opening of the bone tunnel 1170 and the insert 1150 advanced to provisionally lock the suture. In addition, or alternatively, provisional tension in the suture 1160 may be maintained by pressure on the suture from the tunnel wall and the anchor body. In FIG. 37, the insert 1150 has been advanced to the fully locked position and the excess suture 1164 trimmed.

The foregoing examples have illustrated various embodiments of devices and methods useful to attach an elongated strand to a bone by forming a tunnel through the bone, passing the strand through the bone, and then capturing the strand with an anchor. The embodiments have been illustrated in use to repair a rotator cuff of a shoulder joint but it will be understood that the devices and methods are applicable at other surgical sites to attach other implant and tissues to bone. For example, the devices and methods may be used to attach sutures, tendons, ligaments, cables, implant anchor portions, and/or other objects to bone at surgical locations throughout a patient's body. The devices and methods have been shown in use with first and second transverse, linear, intersecting bone tunnels. However, the devices may be used with single linear tunnels through a bone, curved tunnels, three or more intersecting bone tunnels, and/or other bone tunnel configurations.

In the illustrative examples, anchors have been shown securing suture portions at various locations of the anchor. For example, some of the examples have described or depicted fixation at a proximal portion of the anchor and/or at a distal portion of the anchor. The proximal and distal portions of the anchor may refer to distinct proximal and distal ends of the anchor. The proximal and distal portions may refer to relative regions of the anchor such as the proximal one half and distal one half of the anchor, the proximal one third and distal two thirds of the anchor, the proximal two thirds and distal one third or the anchor, or some other fractional part referring to distinct relative zones.

The different illustrative examples have been shown with various forms of bone fixation including threads and annular ridges of varying size and shape. These different forms of fixation may be interchanged within the scope of the invention. For example, where ridges are shown, threads may be substituted and where threads are shown, ridges may be substituted. Any other form of fixation known in the art may also be substituted including but not limited to a smooth press fit.

Some of the illustrative examples have included an insert receivable within an implant body to lock a suture portion relative to the implant body. In these illustrative examples, the insert has been shown as engaging the implant body for axial translation by threading, ratcheting, or smooth press fitting into the implant body. These engagement arrangements may be interchanged among the different plunger embodiments. Furthermore, other features for retaining the insert within the implant body may be incorporated on the insert and/or within the implant body including ridges, grooves, bumps, surface textures, and/or other retaining features. Furthermore, while the illustrative examples have depicted inserts that are moveable from a proximal position to a distal position in which the suture portion is secured, the insert may also be moveable from a distal position to a proximal position in which the suture portion is secured. For example, an insert may be disposed in the implant body distal to a transverse opening and be pulled proximally to secure a suture in the transverse opening. 

What is claimed is:
 1. A method of repairing soft tissue comprising: forming a bone tunnel through a bone adjacent to the soft tissue to be repaired, the bone tunnel having at least first and second spaced apart openings at the surface of the bone; providing a suture and an anchor, a first portion of the suture being attached to the suture anchor and a second portion of the suture being free; placing the second portion of the suture through the bone tunnel and the soft tissue; placing the anchor into one of the bone tunnel openings; and connecting the second portion of the suture to the anchor.
 2. The method of claim 1 further comprising, after placing the anchor into one of the bone tunnel openings, tensioning the suture.
 3. The method of claim 2 further comprising, after tensioning the suture, provisionally connecting the second portion of the suture to the anchor such that tension on the suture is maintained while the provisional connection is easily reversed, and evaluating the soft tissue repair.
 4. The method of claim 3 further comprising, after provisionally connecting the second portion of the suture to the anchor and evaluating the soft tissue repair, adjusting the suture.
 5. The method of claim 1 wherein placing the anchor into one of the bone tunnel openings comprises pulling on the second portion of the suture to advance the anchor into the bone tunnel.
 6. The method of claim 1 wherein the suture comprises at least one suture strand having a first end and a second end, one end of the suture strand being attached to the anchor and the other end being free.
 7. The method of claim 1 wherein the suture comprises at least one closed loop with a first portion of the loop being attached to the anchor and second portion of the loop being free.
 8. The method of claim 1 wherein the first portion of the suture is attached to the anchor by at least one of the methods consisting of tying, molding, crimping, and adhering.
 9. The method of claim 1 wherein the tunnel is formed through the bone as a single continuous path from a first opening on a surface of the bone to a second opening on a surface of the bone.
 10. The method of claim 9 wherein the tunnel is straight.
 11. The method of claim 9 wherein the tunnel is curved.
 12. The method of claim 1 wherein the tunnel is formed through the bone by first and second intersecting bores into the bone.
 13. The method of claim 1 wherein the anchor comprises an elongated body having a proximal end and a distal end, the first portion of the suture being attached to the body at its distal end.
 14. The method of claim 13 wherein a longitudinal passage extends into the body and the anchor further comprises an insert receivable in the passage, the insert being operable to attach the second portion of the suture to the body, the step of connecting the second portion of the suture to the anchor comprising advancing the insert into the longitudinal passage.
 15. The method of claim 14 further comprising, after placing the anchor into one of the bone tunnel openings, tensioning the suture and advancing the insert in the longitudinal passage to a provisional locking position in which tension on the suture is maintained while the insert is still easily retractable to allow for suture adjustment.
 16. The method of claim 15 further comprising, after advancing the insert to the provisional locking position, evaluating the soft tissue repair.
 17. The method of claim 16 further comprising, after evaluating the soft tissue repair, refracting the insert, adjusting the suture, and advancing the suture to the provisional locking position.
 18. The method of claim 17 further comprising advancing the insert to a final locking position in which it is difficult to retract the insert.
 19. The method of claim 14 wherein the second portion of the suture extends distally away from the anchor body, the step of placing the anchor into one of the bone tunnel openings comprising pulling on the second portion of the suture to advance the anchor body into the bone tunnel opening.
 20. The method of claim 14 wherein the insert includes a proximal end and a distal end and an insert aperture formed transversely at least part way through the insert between the proximal and distal ends for receiving the second portion of the suture, the step of connecting the second portion of the suture to the anchor comprising inserting the second portion of the suture into the insert aperture.
 21. The method of claim 14 wherein the suture extends through the passage in the body from the distal end to the proximal end, the anchor further including a body aperture formed transversely at least part way through the body between the proximal and distal ends, the method further comprising: placing the anchor into one of the bone tunnel openings before placing the second portion of the suture through the bone tunnel and the soft tissue; retrieving the second portion of the suture through the body aperture; and then placing the second portion of the suture through the bone tunnel and the soft tissue.
 22. The method of claim 1 wherein the anchor comprises and elongated body having proximal and distal ends, the first portion of the suture being attached to the body at its proximal end.
 23. The method of claim 22 wherein a longitudinal passage extends into the body and the anchor further comprises an insert receivable in the passage, the insert being operable to attach the second portion of the suture to the body, the second portion of the suture extending proximally away from the anchor body, the anchor including a body aperture formed transversely through the body between the proximal and distal ends, the method further comprising: after placing the second portion of the suture through the bone tunnel and the soft tissue, placing the second portion of the suture through the body aperture and pulling it proximally so that the second portion of the suture lies alongside the anchor body; then placing the anchor into one of the bone tunnel openings such that the second portion of the suture is between the tunnel wall and the anchor body; pulling on the second portion of the suture to provisionally tension the soft tissue repair, tension being temporarily maintained by the pressure on the second portion of the suture from the tunnel wall and anchor body; and connecting the second portion of the suture to the anchor by advancing the insert into the longitudinal passage.
 24. The method of claim 13 wherein the first portion of the suture is attached to the body at a position intermediate the proximal and distal ends.
 25. The method of claim 1 wherein forming a bone tunnel through a bone adjacent to the soft tissue to be repaired comprises forming a bone tunnel through a proximal humeral bone adjacent to a rotator cuff.
 26. A method of repairing soft tissue adjacent a shoulder joint comprising a proximal humeral bone and a rotator cuff, the method comprising: forming a bone tunnel through the proximal humeral bone adjacent to the rotator cuff, the bone tunnel having at least first and second spaced apart openings at the surface of the bone; providing a suture and an anchor, a first portion of the suture being attached to the suture anchor and a second portion of the suture being free; placing the second portion of the suture through the bone tunnel and the soft tissue; placing the anchor into one of the bone tunnel openings; and connecting the second portion of the suture to the anchor.
 27. The method of claim 26 wherein a longitudinal passage extends into the body and the anchor further comprises an insert receivable in the passage, the insert being operable to attach the second portion of the suture to the body, the step of connecting the second portion of the suture to the anchor comprising advancing the insert into the longitudinal passage. 